HIV and Hepatitis C–Coinfected Patients Have Lower Low‐Density Lipoprotein Cholesterol Despite Higher Proprotein Convertase Subtilisin Kexin 9 ( PCSK 9): An Apparent “ PCSK 9–Lipid Paradox”

Background Proprotein convertase subtilisin kexin 9 ( PCSK 9) inhibitors reduce low‐density lipoprotein cholesterol ( LDL ‐C) and improve outcomes in the general population. HIV ‐infected individuals are at increased risk for cardiovascular events and have high rates of dyslipidemia and hepatitis C virus ( HCV ) coinfection, making PCSK 9 inhibition a potentially attractive therapy. Methods and Results We studied 567 participants from a clinic‐based cohort to compare PCSK 9 levels in patients with HIV / HCV coinfection (n=110) with those with HIV infection alone (n=385) and with uninfected controls (n=72). The mean age was 49 years, and the median LDL ‐C level was 100 mg/dL ( IQR 77–124 mg/dL); 21% were taking statins. The 3 groups had similar rates of traditional risk factors. Total cholesterol, LDL ‐C, and high‐density lipoprotein cholesterol levels were lower in coinfected patients compared with controls ( P <0.001). PCSK 9 was 21% higher in HIV / HCV ‐coinfected patients versus controls (95% CI 9–34%, P <0.001) and 11% higher in coinfected individuals versus those with HIV infection alone (95% CI 3–20%, P =0.008). After adjustment for cardiovascular risk factors, HIV / HCV coinfection remained significantly associated with 20% higher PCSK 9 levels versus controls (95% CI 8–33%, P =0.001). Interleukin‐6 levels increased in a stepwise fashion from controls (lowest) to HIV ‐infected to HIV / HCV ‐coinfected individuals (highest) and correlated with PCSK 9 ( r =0.11, P =0.018). Conclusions Despite having lower LDL ‐C, circulating PCSK 9 levels were increased in patients coinfected with HIV and HCV in parallel with elevations in the inflammatory, proatherogenic cytokine interleukin‐6. Clinical trials should be conducted to determine the efficacy of targeted PCSK 9 inhibition in the setting of HIV / HCV coinfection.